Are gadgets gathering dust in your ED? Ask a few questions before jumping on the next tech trend
“The philosophies of one age have become the absurdities of the
next, and the foolishness of yesterday has become the wisdom of
~Sir William Osler.
I have no interest this month in sounding like a malignant Luddite. I am not against all change; some change may actually be good. But, we cannot confuse change with progress. The two have nothing to do with each other. There are people who change for no good reason. There was time in the United States when it was considered important to have the next year’s generation of an automobile, simply because in 1953 you did not want to have a 1952 Chevy. This type of ridiculousness goes on and on in everything.
I know that I am not the ideal person to speak about technological change. I am considered by my own group to be the chuckhole on the information super highway. I am the Ventura off ramp of modern machinery. But having said that, there is some justification in my warning. We have been watching so many drugs, machines and philosophies of health care turn to stool just in my lifetime in medicine that I think some intelligence skepticism is required. Remembering the fact that a critical analysis is necessary if we are going to spend other people’s money. Let’s take a leisurely journey through the emergency department. Be honest. As you walk through the department, you are going to find multitudes of pieces of equipment that are gathering dust. You have no idea why you purchased them. Everyone was gung-ho early on, and now they lay extinct, dinosaurs in the intellectual elephant burial ground of useless machinery. As you sit and look at the various devices you have seen come and go over the years, you can’t help but shake your head and wonder what you were thinking at that moment in time. It is good to remember, as Gilbert & Sullivan put it: “All things are not what they seem, skim milk oft times masquerades as cream.” The principle that should drive the addition of technology is usefulness in obtaining patient-orientated results of some kind. That patient-orientated evidence is what I want to see. Most of our publications are divided between patient-orientated evidence and disease-orientated evidence. I don’t care that a new device can raise or lower blood pressure or increase or decrease glucose levels. I want to know if the patient has a better result. There are things that need to drive us, and we have to be afraid of intellectually-deficient thinking. The post-hoc argument is dangerous. Just because we have applied a therapy and we have gotten some numerical change doesn’t relate to a better outcome, better quality of life, less pain and more joy to the humans we are in charge of taking care of. As emergency physicians, we have an obligation to the patients and to ourselves to critically ask questions about any imposed change, and failing to do that is failing in our responsibilities as physicians. The technician knows everything about his job, and the physician understands how the science and technology can actually be integrated to give someone a better life.
It is essential that we have a primary end point, which we can understand. Over the last five years, we have learned that the tight control of glucose is actually a negative as opposed to a positive, when managing diabetics. There is growing evidence that tight control of cholesterol has nothing to do with who is going to have a heart attack. Just because we can chase a number does not mean that we have improved anyone’s life. Within the past two weeks, an article has appeared in the Journal of American Medical Association, which again confounds and shakes us at our very roots. This has to do with the initial systolic blood pressure when entering the ICU. We have learned for years that we want very tight blood pressure control. In looking at this rather extensive study, nothing could be farther from the truth. Don’t get me wrong, I hate this paper. It shakes one of the core foundations of my view of health care. But we have to understand that occasionally a beautiful fact is destroyed by clinical results. This is what’s happening, and we have to learn to live with it. The British raconteur Samuel Johnson reminds us that change is never made without inconvenience. Rapid change, no matter what area of medicine it is in, is always difficult. And rapid change – or change for the sake of change – is the philosophy of the cancer cell. We are always caught on an ever-hurling wheel of change. Knowing when to jump in and to jump out is the key. I remember going to the electronics store to buy my first CD player. I made the man at the store promise on the spot that this was the last invention that they are going to create during my lifetime, so I didn’t have to switch over to another system. That was four changes ago, and I still don’t know what to do with the LPs stacked up in my closet.
Let me put forward some ideas as we look at innovation in medicine. Ask yourself the following questions whenever some new drug, piece of equipment or change in administration or process flow is imposed. First, how often will this new device be used? Who is going to use it, and how is going to benefit our patients? Again, a new device is only as good as the people who are using it. The military has dealt with this problem for years. You can’t have a more complex system than the human beings you have to deal with can use. Often times, new devices, such as a new tool for intubation, seem interesting. But if in a crisis situation no one uses it, what good is it? I’ll tell you right now, I am an old guy. When I managed an airway, I used the old-fashioned way with the handle, blade and ET-tube. Why? Because that is how I had done it a thousand times, and how I felt most comfortable in an emergency situation.
There certainly have been better things that have come along that have made my life easier and essentially put the surgical Greco-thyrotomy on the shelf. But there is no question we all go back to what we are clinically best at.
The second question is the cost. No matter how good a device is, it is only worth so much money. Sometimes minimal qualities of improvement have nothing to do with a value-added service for our patients. The best example is monophasic vs. biphasic defibrillators. What are we to do? Are we to throw out perfectly good defibrillators simply because there is a disease-based observation for which the biphasic might be superior? The actual clinical application has shown no advantage one over the other. I see no reason to throw out perfectly good equipment that is not a specific benefit to the patients. Cost does matter and should be figured in when solving problems.
The third question is what happens when our newest toy doesn’t work. Before you invest money in one system of anything, make sure that the back up is in place. Nothing could be a better example of this than certain of the electronic medical records. Electronic medical records have, so far, proven to take up more physicians time, makes us less efficient, make the nursing notes hidden from the doctor, and, when the system goes down, it causes confusion for everyone. No matter what new systems we employ, we need to take into account the fact that increasing technology also means logarithmically increasing problems. If you are not able to work around those problems, then maybe the system is not ready at this moment in time.
Lastly, what resources or requirements are necessary with any new system? If the amount of time off the job to train doctors, nurses, PAs, techs, etc. means that you are not adequately covering – or it threatens the provision of service at this moment in time – rethink the issue. To believe that more complexity replaces intelligent thinking is ridiculous. I am sitting as I compose this diatribe looking at two medical-legal cases in which the MRI scans were only suggestive or questionable. There was no question on the part of the physician that the history and physical were compatible with a certain disease, and yet, they got sucked into believing the reading of a physician who has not seen the patient and has employed an $8 million machine, opposed to general intelligence and on-sight familiarity with a patient. Technology has its good and bad aspects. For any of us to believe that technology will replace the overall intelligence of a mature and well-trained and continuously monitoring physician is folly.